Arizona 2022 Regular Session

Arizona Senate Bill SB1395 Compare Versions

Only one version of the bill is available at this time.

Old	New	Differences
1	1	REFERENCE TITLE: mental health medication; prior authorization State of Arizona Senate Fifty-fifth Legislature Second Regular Session 2022 SB 1395 Introduced by Senator Shope AN ACT amending sections 20-3402 and 36-2907, arizona revised statutes; relating to medical insurance. (TEXT OF BILL BEGINS ON NEXT PAGE)
2	2
3	3
4	4
5	5
6	6
7	7
8	8
9	9	REFERENCE TITLE: mental health medication; prior authorization
10	10	State of Arizona Senate Fifty-fifth Legislature Second Regular Session 2022
11	11	SB 1395
12	12	Introduced by Senator Shope
13	13
14	14	REFERENCE TITLE: mental health medication; prior authorization
15	15
16	16
17	17
18	18
19	19
20	20
21	21
22	22
23	23
24	24	State of Arizona
25	25
26	26	Senate
27	27
28	28	Fifty-fifth Legislature
29	29
30	30	Second Regular Session
31	31
32	32	2022
33	33
34	34
35	35
36	36
37	37
38	38	SB 1395
39	39
40	40
41	41
42	42	Introduced by
43	43
44	44	Senator Shope
45	45
46	46
47	47
48	48
49	49
50	50	AN ACT
51	51
52	52
53	53
54	54	amending sections 20-3402 and 36-2907, arizona revised statutes; relating to medical insurance.
55	55
56	56
57	57
58	58
59	59
60	60	(TEXT OF BILL BEGINS ON NEXT PAGE)
61	61
62	62
63	63
64	64	Be it enacted by the Legislature of the State of Arizona: Section 1. Section 20-3402, Arizona Revised Statutes, is amended to read: START_STATUTE20-3402. Prior authorization; exceptions A. A health care services plan or its utilization review agent may impose a prior authorization requirement for health care services provided to an enrollee, except for emergency ambulance services and emergency services as specified in section 20-2803, health care services arising after the initial medical screening examination and immediately necessary stabilizing treatment as specified in section 20-2803. B. A health care services plan must allow at least one modality of medication-assisted treatment to be available without prior authorization. C. a health care services plan or its utilization review agent shall cover, without prior authorization, any prescribed drug for the treatment of a mental disorder if all of the following apply: 1. The drug is prescribed to assess or treat an enrollee's serious mental illness. For the purposes of this paragraph, "serious mental illness" means a mental disorder, as defined in the most recent edition of the diagnostic and statistical manual of mental disorders of the american psychiatric association, that results in serious functional impairment and that substantially interferes with or limits one or more major life activities. 2. The drug is a covered benefit. 3. The prescriber indicates the drug is medically necessary as defined in section 20-3651. 4. The prescription does not exceed the dosage amount recommended by the United States Food and Drug administration. 5. The prescriber performs an annual review of the patient to evaluate the prescription drug's continued efficacy, changes in the patient's health status and potential contraindications. END_STATUTE Sec. 2. Section 36-2907, Arizona Revised Statutes, is amended to read: START_STATUTE36-2907. Covered health and medical services; modifications; related delivery of service requirements; definition A. Subject to the limitations limits and exclusions specified in this section, contractors shall provide the following medically necessary health and medical services: 1. Inpatient hospital services that are ordinarily furnished by a hospital for the to care for and treatment of treat inpatients and that are provided under the direction of a physician or a primary care practitioner. For the purposes of this section, inpatient hospital services exclude services in an institution for tuberculosis or mental diseases unless authorized under an approved section 1115 waiver. 2. Outpatient health services that are ordinarily provided in hospitals, clinics, offices and other health care facilities by licensed health care providers. Outpatient health services include services provided by or under the direction of a physician or a primary care practitioner, including occupational therapy. 3. Other laboratory and X-ray services ordered by a physician or a primary care practitioner. 4. Medications that are ordered on prescription by a physician or a dentist licensed pursuant to title 32, chapter 11. Persons who are dually eligible for title XVIII and title XIX services must obtain available medications through a medicare licensed or certified medicare advantage prescription drug plan, a medicare prescription drug plan or any other entity authorized by medicare to provide a medicare part D prescription drug benefit. drugs prescribed for the treatment of a mental disorder are not subject to any prior authorization requirement, step therapy or other protocol that could restrict or delay dispensing the drug if all of the following apply: (a) The drug is prescribed to assess or treat a person's serious mental illness. For the purposes of this subdivision, "serious mental illness" means a mental disorder, as defined in the most recent edition of the diagnostic and statistical manual of mental disorders of the american psychiatric association, that results in serious functional impairment and that substantially interferes with or limits one or more major life activities. (b) The drug is a covered benefit. (c) The prescription does not exceed the dosage amount recommended by the United States Food and Drug administration. (d) The prescriber performs an annual review of the patient to evaluate the prescription drug's continued efficacy, changes in the patient's health status and potential contraindications. 5. Medical supplies, durable medical equipment, insulin pumps and prosthetic devices ordered by a physician or a primary care practitioner. Suppliers of durable medical equipment shall provide the administration with complete information about the identity of each person who has an ownership or controlling interest in their business and shall comply with federal bonding requirements in a manner prescribed by the administration. 6. For persons who are at least twenty-one years of age, treatment of medical conditions of the eye, excluding eye examinations for prescriptive lenses and the provision of prescriptive lenses. 7. Early and periodic health screening and diagnostic services as required by section 1905(r) of title XIX of the social security act for members who are under twenty-one years of age. 8. Family planning services that do not include abortion or abortion counseling. If a contractor elects not to provide family planning services, this election does not disqualify the contractor from delivering all other covered health and medical services under this chapter. In that event, the administration may contract directly with another contractor, including an outpatient surgical center or a noncontracting provider, to deliver family planning services to a member who is enrolled with the contractor that elects not to provide family planning services. 9. Podiatry services that are performed by a podiatrist who is licensed pursuant to title 32, chapter 7 and ordered by a primary care physician or primary care practitioner. 10. Nonexperimental transplants approved for title XIX reimbursement. 11. Dental services as follows: (a) Except as provided in subdivision (b) of this paragraph, for persons who are at least twenty-one years of age, emergency dental care and extractions in an annual amount of not more than $1,000 per member. (b) Subject to approval by the centers for medicare and medicaid services, for persons treated at an Indian health service or tribal facility, adult dental services that are eligible for a federal medical assistance percentage of one hundred percent and that are in excess of exceed the limit prescribed in subdivision (a) of this paragraph. 12. Ambulance and nonambulance transportation, except as provided in subsection G of this section. 13. Hospice care. 14. Orthotics, if all of the following apply: (a) The use of the orthotic is medically necessary as the preferred treatment option consistent with medicare guidelines. (b) The orthotic is less expensive than all other treatment options or surgical procedures to treat the same diagnosed condition. (c) The orthotic is ordered by a physician or primary care practitioner. B. The limitations limits and exclusions for health and medical services provided under this section are as follows: 1. Circumcision of newborn males is not a covered health and medical service. 2. For eligible persons who are at least twenty-one years of age: (a) Outpatient health services do not include speech therapy. (b) Prosthetic devices do not include hearing aids, dentures, bone-anchored hearing aids or cochlear implants. Prosthetic devices, except prosthetic implants, may be limited to $12,500 per contract year. (c) Percussive vests are not covered health and medical services. (d) Durable medical equipment is limited to items covered by medicare. (e) Nonexperimental transplants do not include pancreas-only transplants. (f) Bariatric surgery procedures, including laparoscopic and open gastric bypass and restrictive procedures, are not covered health and medical services. C. The system shall pay noncontracting providers only for health and medical services as prescribed in subsection A of this section and as prescribed by rule. D. The director shall adopt rules necessary to limit, to the extent possible, the scope, duration and amount of services, including maximum limitations limits for inpatient services that are consistent with federal regulations under title XIX of the social security act (P.L. 89-97; 79 Stat. 344; 42 United States Code section 1396 (1980)). To the extent possible and practicable, these rules shall provide for the prior approval of medically necessary services provided pursuant to this chapter. E. The director shall make available home health services in lieu of hospitalization pursuant to contracts awarded under this article. For the purposes of this subsection, "home health services" means the provision of nursing services, home health aide services or medical supplies, equipment and appliances that are provided on a part-time or intermittent basis by a licensed home health agency within a member's residence based on the orders of a physician or a primary care practitioner. Home health agencies shall comply with the federal bonding requirements in a manner prescribed by the administration. F. The director shall adopt rules for the coverage of behavioral health services for persons who are eligible under section 36-2901, paragraph 6, subdivision (a). The administration acting through the regional behavioral health authorities shall establish a diagnostic and evaluation program to which other state agencies shall refer children who are not already enrolled pursuant to this chapter and who may be in need of behavioral health services. In addition to an evaluation, the administration acting through regional behavioral health authorities shall also identify children who may be eligible under section 36-2901, paragraph 6, subdivision (a) or section 36-2931, paragraph 5 and shall refer the children to the appropriate agency responsible for making the final eligibility determination. G. The director shall adopt rules providing for transportation services and rules providing for copayment by members for transportation for other than emergency purposes. Subject to approval by the centers for medicare and medicaid services, nonemergency medical transportation shall not be provided except for stretcher vans and ambulance transportation. Prior authorization is required for transportation by stretcher van and for medically necessary ambulance transportation initiated pursuant to a physician's direction. Prior authorization is not required for medically necessary ambulance transportation services rendered to members or eligible persons initiated by dialing telephone number 911 or other designated emergency response systems. H. The director may adopt rules to allow the administration, at the director's discretion, to use a second opinion procedure under which surgery may not be eligible for coverage pursuant to this chapter without documentation as to need by at least two physicians or primary care practitioners. I. If the director does not receive bids within the amounts budgeted or if at any time the amount remaining in the Arizona health care cost containment system fund is insufficient to pay for full contract services for the remainder of the contract term, the administration, on notification to system contractors at least thirty days in advance, may modify the list of services required under subsection A of this section for persons defined as eligible other than those persons defined pursuant to section 36-2901, paragraph 6, subdivision (a). The director may also suspend services or may limit categories of expense for services defined as optional pursuant to title XIX of the social security act (P.L. 89-97; 79 Stat. 344; 42 United States Code section 1396 (1980)) for persons defined pursuant to section 36-2901, paragraph 6, subdivision (a). Such reductions or suspensions do not apply to the continuity of care for persons already receiving these services. J. All health and medical services provided under this article shall be provided in the geographic service area of the member, except: 1. Emergency services and specialty services provided pursuant to section 36-2908. 2. That the director may allow the delivery of health and medical services in other than the geographic service area in this state or in an adjoining state if the director determines that medical practice patterns justify the delivery of services or a net reduction in transportation costs can reasonably be expected. Notwithstanding the definition of physician as prescribed in section 36-2901, if services are procured from a physician or primary care practitioner in an adjoining state, the physician or primary care practitioner shall be licensed to practice in that state pursuant to licensing statutes in that state that are similar to title 32, chapter 13, 15, 17 or 25 and shall complete a provider agreement for this state. K. Covered outpatient services shall be subcontracted by a primary care physician or primary care practitioner to other licensed health care providers to the extent practicable for purposes including, but not limited to, making health care services available to underserved areas, reducing costs of providing medical care and reducing transportation costs. L. The director shall adopt rules that prescribe the coordination of medical care for persons who are eligible for system services. The rules shall include provisions for transferring patients and medical records and initiating medical care. M. For the purposes of this section, "ambulance" has the same meaning prescribed in section 36-2201. END_STATUTE
65	65
66	66	Be it enacted by the Legislature of the State of Arizona:
67	67
68	68	Section 1. Section 20-3402, Arizona Revised Statutes, is amended to read:
69	69
70	70	START_STATUTE20-3402. Prior authorization; exceptions
71	71
72	72	A. A health care services plan or its utilization review agent may impose a prior authorization requirement for health care services provided to an enrollee, except for emergency ambulance services and emergency services as specified in section 20-2803, health care services arising after the initial medical screening examination and immediately necessary stabilizing treatment as specified in section 20-2803.
73	73
74	74	B. A health care services plan must allow at least one modality of medication-assisted treatment to be available without prior authorization.
75	75
76	76	C. a health care services plan or its utilization review agent shall cover, without prior authorization, any prescribed drug for the treatment of a mental disorder if all of the following apply:
77	77
78	78	1. The drug is prescribed to assess or treat an enrollee's serious mental illness. For the purposes of this paragraph, "serious mental illness" means a mental disorder, as defined in the most recent edition of the diagnostic and statistical manual of mental disorders of the american psychiatric association, that results in serious functional impairment and that substantially interferes with or limits one or more major life activities.
79	79
80	80	2. The drug is a covered benefit.
81	81
82	82	3. The prescriber indicates the drug is medically necessary as defined in section 20-3651.
83	83
84	84	4. The prescription does not exceed the dosage amount recommended by the United States Food and Drug administration.
85	85
86	86	5. The prescriber performs an annual review of the patient to evaluate the prescription drug's continued efficacy, changes in the patient's health status and potential contraindications. END_STATUTE
87	87
88	88	Sec. 2. Section 36-2907, Arizona Revised Statutes, is amended to read:
89	89
90	90	START_STATUTE36-2907. Covered health and medical services; modifications; related delivery of service requirements; definition
91	91
92	92	A. Subject to the limitations limits and exclusions specified in this section, contractors shall provide the following medically necessary health and medical services:
93	93
94	94	1. Inpatient hospital services that are ordinarily furnished by a hospital for the to care for and treatment of treat inpatients and that are provided under the direction of a physician or a primary care practitioner. For the purposes of this section, inpatient hospital services exclude services in an institution for tuberculosis or mental diseases unless authorized under an approved section 1115 waiver.
95	95
96	96	2. Outpatient health services that are ordinarily provided in hospitals, clinics, offices and other health care facilities by licensed health care providers. Outpatient health services include services provided by or under the direction of a physician or a primary care practitioner, including occupational therapy.
97	97
98	98	3. Other laboratory and X-ray services ordered by a physician or a primary care practitioner.
99	99
100	100	4. Medications that are ordered on prescription by a physician or a dentist licensed pursuant to title 32, chapter 11. Persons who are dually eligible for title XVIII and title XIX services must obtain available medications through a medicare licensed or certified medicare advantage prescription drug plan, a medicare prescription drug plan or any other entity authorized by medicare to provide a medicare part D prescription drug benefit. drugs prescribed for the treatment of a mental disorder are not subject to any prior authorization requirement, step therapy or other protocol that could restrict or delay dispensing the drug if all of the following apply:
101	101
102	102	(a) The drug is prescribed to assess or treat a person's serious mental illness. For the purposes of this subdivision, "serious mental illness" means a mental disorder, as defined in the most recent edition of the diagnostic and statistical manual of mental disorders of the american psychiatric association, that results in serious functional impairment and that substantially interferes with or limits one or more major life activities.
103	103
104	104	(b) The drug is a covered benefit.
105	105
106	106	(c) The prescription does not exceed the dosage amount recommended by the United States Food and Drug administration.
107	107
108	108	(d) The prescriber performs an annual review of the patient to evaluate the prescription drug's continued efficacy, changes in the patient's health status and potential contraindications.
109	109
110	110	5. Medical supplies, durable medical equipment, insulin pumps and prosthetic devices ordered by a physician or a primary care practitioner. Suppliers of durable medical equipment shall provide the administration with complete information about the identity of each person who has an ownership or controlling interest in their business and shall comply with federal bonding requirements in a manner prescribed by the administration.
111	111
112	112	6. For persons who are at least twenty-one years of age, treatment of medical conditions of the eye, excluding eye examinations for prescriptive lenses and the provision of prescriptive lenses.
113	113
114	114	7. Early and periodic health screening and diagnostic services as required by section 1905(r) of title XIX of the social security act for members who are under twenty-one years of age.
115	115
116	116	8. Family planning services that do not include abortion or abortion counseling. If a contractor elects not to provide family planning services, this election does not disqualify the contractor from delivering all other covered health and medical services under this chapter. In that event, the administration may contract directly with another contractor, including an outpatient surgical center or a noncontracting provider, to deliver family planning services to a member who is enrolled with the contractor that elects not to provide family planning services.
117	117
118	118	9. Podiatry services that are performed by a podiatrist who is licensed pursuant to title 32, chapter 7 and ordered by a primary care physician or primary care practitioner.
119	119
120	120	10. Nonexperimental transplants approved for title XIX reimbursement.
121	121
122	122	11. Dental services as follows:
123	123
124	124	(a) Except as provided in subdivision (b) of this paragraph, for persons who are at least twenty-one years of age, emergency dental care and extractions in an annual amount of not more than $1,000 per member.
125	125
126	126	(b) Subject to approval by the centers for medicare and medicaid services, for persons treated at an Indian health service or tribal facility, adult dental services that are eligible for a federal medical assistance percentage of one hundred percent and that are in excess of exceed the limit prescribed in subdivision (a) of this paragraph.
127	127
128	128	12. Ambulance and nonambulance transportation, except as provided in subsection G of this section.
129	129
130	130	13. Hospice care.
131	131
132	132	14. Orthotics, if all of the following apply:
133	133
134	134	(a) The use of the orthotic is medically necessary as the preferred treatment option consistent with medicare guidelines.
135	135
136	136	(b) The orthotic is less expensive than all other treatment options or surgical procedures to treat the same diagnosed condition.
137	137
138	138	(c) The orthotic is ordered by a physician or primary care practitioner.
139	139
140	140	B. The limitations limits and exclusions for health and medical services provided under this section are as follows:
141	141
142	142	1. Circumcision of newborn males is not a covered health and medical service.
143	143
144	144	2. For eligible persons who are at least twenty-one years of age:
145	145
146	146	(a) Outpatient health services do not include speech therapy.
147	147
148	148	(b) Prosthetic devices do not include hearing aids, dentures, bone-anchored hearing aids or cochlear implants. Prosthetic devices, except prosthetic implants, may be limited to $12,500 per contract year.
149	149
150	150	(c) Percussive vests are not covered health and medical services.
151	151
152	152	(d) Durable medical equipment is limited to items covered by medicare.
153	153
154	154	(e) Nonexperimental transplants do not include pancreas-only transplants.
155	155
156	156	(f) Bariatric surgery procedures, including laparoscopic and open gastric bypass and restrictive procedures, are not covered health and medical services.
157	157
158	158	C. The system shall pay noncontracting providers only for health and medical services as prescribed in subsection A of this section and as prescribed by rule.
159	159
160	160	D. The director shall adopt rules necessary to limit, to the extent possible, the scope, duration and amount of services, including maximum limitations limits for inpatient services that are consistent with federal regulations under title XIX of the social security act (P.L. 89-97; 79 Stat. 344; 42 United States Code section 1396 (1980)). To the extent possible and practicable, these rules shall provide for the prior approval of medically necessary services provided pursuant to this chapter.
161	161
162	162	E. The director shall make available home health services in lieu of hospitalization pursuant to contracts awarded under this article. For the purposes of this subsection, "home health services" means the provision of nursing services, home health aide services or medical supplies, equipment and appliances that are provided on a part-time or intermittent basis by a licensed home health agency within a member's residence based on the orders of a physician or a primary care practitioner. Home health agencies shall comply with the federal bonding requirements in a manner prescribed by the administration.
163	163
164	164	F. The director shall adopt rules for the coverage of behavioral health services for persons who are eligible under section 36-2901, paragraph 6, subdivision (a). The administration acting through the regional behavioral health authorities shall establish a diagnostic and evaluation program to which other state agencies shall refer children who are not already enrolled pursuant to this chapter and who may be in need of behavioral health services. In addition to an evaluation, the administration acting through regional behavioral health authorities shall also identify children who may be eligible under section 36-2901, paragraph 6, subdivision (a) or section 36-2931, paragraph 5 and shall refer the children to the appropriate agency responsible for making the final eligibility determination.
165	165
166	166	G. The director shall adopt rules providing for transportation services and rules providing for copayment by members for transportation for other than emergency purposes. Subject to approval by the centers for medicare and medicaid services, nonemergency medical transportation shall not be provided except for stretcher vans and ambulance transportation. Prior authorization is required for transportation by stretcher van and for medically necessary ambulance transportation initiated pursuant to a physician's direction. Prior authorization is not required for medically necessary ambulance transportation services rendered to members or eligible persons initiated by dialing telephone number 911 or other designated emergency response systems.
167	167
168	168	H. The director may adopt rules to allow the administration, at the director's discretion, to use a second opinion procedure under which surgery may not be eligible for coverage pursuant to this chapter without documentation as to need by at least two physicians or primary care practitioners.
169	169
170	170	I. If the director does not receive bids within the amounts budgeted or if at any time the amount remaining in the Arizona health care cost containment system fund is insufficient to pay for full contract services for the remainder of the contract term, the administration, on notification to system contractors at least thirty days in advance, may modify the list of services required under subsection A of this section for persons defined as eligible other than those persons defined pursuant to section 36-2901, paragraph 6, subdivision (a). The director may also suspend services or may limit categories of expense for services defined as optional pursuant to title XIX of the social security act (P.L. 89-97; 79 Stat. 344; 42 United States Code section 1396 (1980)) for persons defined pursuant to section 36-2901, paragraph 6, subdivision (a). Such reductions or suspensions do not apply to the continuity of care for persons already receiving these services.
171	171
172	172	J. All health and medical services provided under this article shall be provided in the geographic service area of the member, except:
173	173
174	174	1. Emergency services and specialty services provided pursuant to section 36-2908.
175	175
176	176	2. That the director may allow the delivery of health and medical services in other than the geographic service area in this state or in an adjoining state if the director determines that medical practice patterns justify the delivery of services or a net reduction in transportation costs can reasonably be expected. Notwithstanding the definition of physician as prescribed in section 36-2901, if services are procured from a physician or primary care practitioner in an adjoining state, the physician or primary care practitioner shall be licensed to practice in that state pursuant to licensing statutes in that state that are similar to title 32, chapter 13, 15, 17 or 25 and shall complete a provider agreement for this state.
177	177
178	178	K. Covered outpatient services shall be subcontracted by a primary care physician or primary care practitioner to other licensed health care providers to the extent practicable for purposes including, but not limited to, making health care services available to underserved areas, reducing costs of providing medical care and reducing transportation costs.
179	179
180	180	L. The director shall adopt rules that prescribe the coordination of medical care for persons who are eligible for system services. The rules shall include provisions for transferring patients and medical records and initiating medical care.
181	181
182	182	M. For the purposes of this section, "ambulance" has the same meaning prescribed in section 36-2201. END_STATUTE